Tag Archives: study

In the abstract, the authors suggest that people with autism spectrum disorders (ASD) “often have identity crises which sometimes include gender dysphoria.” They speculate that when people with ASD become teenagers, they “realize their uniqueness and differences compared to others, and, as a result, they may develop confusion of identity which could be exhibited as gender identity disorder.”

They talk about a recent study that found that “amongst 204 children and adolescents who visited a GID clinic in the Netherlands, 7.8% were diagnosed with autism spectrum disorders after a careful diagnostic procedure by a multi-disciplinary team.”

The paper looks at four cases of young people with both ASD and either gender dysphoria or “related symptoms.” Their study included:

“1) a girl with PDD (pervasive developmental disorders=autism/ASD) who repeatedly asserted gender identity disorder (GID) symptoms in response to social isolation at school,

2) a junior high school boy with PDD and transvestism,

3) a boy diagnosed with Asperger’s disorder who developed a disturbance of sexual orientation, and

4) a boy with Asperger’s disorder and comorbid childhood GID.”

They believe that “Many of the clinical symptoms related to gender dysphoria might be explained by the cognitive characteristics and psychopathology of PDD.”

Without seeing more, it is hard to evaluate this study.

Nevertheless, they do not seem to have proven their case very well. Two of the four people they discuss do not sound like they have gender dysphoria.

For the other two children, it would help to know more details – did they outgrow the gender dysphoria? do they now believe that they were wrong about their gender? could they have gender dysphoria and ASD?

The authors conclude by saying that gender dysphoria has become more well-known in Japan and they are seeing more patients complaining of it.

They believe that it is important to consider an underlying diagnosis of ASD for patients with gender dysphoria; I can agree with that conclusion at least.

In the past, researchers have found that people with gender identity disorder are more likely to have autism spectrum disorders than the general public. This study came at the question from the other direction. They looked at children with autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), or a medical neurodevelopmental disorder to see if they were gender variant.

They measured gender variance by scores on the Child Behavior Checklist (CBCL) that parents had filled out. They compared the children’s scores to two control groups and the standarized scores for the CBCL.

The study found that children with ASD and ADHD were more likely to express gender variance, at least as measured by the CBCL. The children with medical neurodevelopmental disorders were not more likely to be gender variant.

This is a very intriguing, although limited, result. These children were not actually tested to see if they had gender dysphoria. What exactly does it mean that they had more gender variance than other children? Were they more likely to play with children of the opposite sex? Did they prefer toys and activities we see as suitable for the opposite sex? Did they dress differently than other children?

The big question here is whether or not these children actually wanted to be the opposite sex. If not, they did not have gender dysphoria.

Another important question is whether the children were naturally more like the other sex or just didn’t understand the socially approved gender roles, either due to ASD or to not paying attention.

On the other hand, given that children with gender dysphoria are more likely to have ASD than usual, it might be that children with ASD have more gender dysphoria than we realize.

An interesting tangent – there may be a link between ASD and ADHD. It’s not clear if they share an underlying cause or genetic predisposition or not. If there is a common cause, might it also be linked to gender dysphoria?

As usual, we need a follow-up study in this area. A useful study would look at what percentage of children, teens, and adults with ASD or ADHD have gender dysphoria.

“We describe the case of a 23-year-old woman with Gender Identity Disorder (GID) asking for a cross-sex hormonal treatment with sex reassignment surgery and who was recently diagnosed with Autism Spectrum Disorder (ASD). Gender identity clinics are now reporting an overrepresentation of individuals with ASD among GID patients. The prevalence of ASD is 10-fold higher among GID patients than in general population.”

This paper is mostly a detailed discussion of a young woman with gender dysphoria who was found to have autism during her treatment. The therapists worked with her to provide therapy in other areas before her sex reassignment surgery. She eventually came back for the surgery.

The authors say that there have only been 10 other published case studies of people with both gender dysphoria and Asperger’s or high-functioning autism (the cases looked at six young boys, two young girls, one adult man, and one adult woman). I think they may have missed a 2014 article I reviewed that looked at two adult men.

This is the first case study about someone with gender dysphoria and “typical autism and borderline intelligence.”

I found their general discussion of the issue to be the most interesting part of the article.

Diagnoses of autism and gender dysphoria are both rising:

“The prevalence of ASD is around 60–70 per 10,000. This increase of prevalence is mostly due to the improvement in diagnostic procedures (Fombonne, 2009). ASD begins in childhood and persists in adulthood, and is clinically characterized by impaired social interactions and communication and restricted and repetitive behaviors and interests. Mental retardation is not the rule and around 30 % (Fombonne, 2005) and recently 62 % (Autism and Developmental Disabilities Monitoring Network Surveillance Year 2008 Principal Investigators, 2012) of ASD patients did not have intellectual disability (IQ ≤ 70). This form of ASD without mental retardation is often misdiagnosed.

The prevalence of GID (ranging from 1 per 11,900 to 1 per 45,000 for male-to-female individuals and 1 per 30,400 to 1 per 200,000 for female-to-male individuals) seems to be rising as well, at least as reflected by referrals to GID clinics (De Cuypere et al.,2007). Reed, Rhodes, Schofield, and Wylie (2009) reported a doubling of the numbers of people accessing care at gender clinics in the United Kingdom every 5 or 6 years. Similarly, Zucker, Bradley, Owen-Anderson, Kibblewhite, and Cantor (2008) reported a four- to five-fold increase in child and adolescent referrals to their Toronto, Canada clinic over a 30-year period and, in their last report, this increase persisted (Wood et al., 2013).”

One study found that children and teens with gender dysphoria were more likely to have autism spectrum disorder than is usual:

“There are very few published studies describing the use of systematic measures for this co-occurrence. In a sample of 204 children and adolescents with GID referred to a gender identity clinic, the incidence of ASD was 7.8 %. Thus, the prevalence of ASD in this population was 10-fold higher than that in the general population (de Vries et al., 2010).”

This might confuse the diagnosis:

“This co-occurrence is relevant for diagnostic and clinical management. First, it is important to disentangle whether the gender dysphoria arose from a general feeling of being “different” or from a “core” cross-gender identity (de Vries et al., 2010). De Vries et al. suggested that the diagnostic procedure has to include consideration of the contributions of the rigidity and reality of attitudes to gender roles and of difficulties in developing aspects of personal identity.”

“In our case, the GID may have masked the diagnosis of ASD which was not treated, and the ASD may have enhanced the GID symptomatology. Hence, ASD rigidity and maybe low IQ may contribute to the difficulty in coping with gender dysphoria, especially without sex reassignment surgery like most gender dysphoric people do.”

A patient with autism might still get sex reassignment, but first there should be rehabilitation for other issues:

“De Vries et al. do not believe that ASD is a strict exclusion criterion for sex reassignment. There has been only one case report describing a woman with Asperger’s disorder who received sex reassignment (Kraemer et al., 2005), although more cases are known in clinical practice (Gallucci et al., 2005). However, if ASD is diagnosed, rehabilitation centered on social interactions and communication should be proposed before sex reassignment surgery. In the case of Ms. G, although she consistently and resolutely requested the sex reassignment surgery, the requests stopped temporally once rehabilitation was proposed.” (I think they mean the requests stopped temporarily.)

It could be that gender dysphoria is related to autism because autism is an example of an extreme male brain:*

“This co-occurrence also raises important theoretical questions regarding gender identity in autism. There are four times as many males than females with autism and this has led to an extreme male brain theory (EBT) being developed to explain the physiopathological process (Auyeung et al., 2009). The EBT is an extension of the empathizing–systemizing theory of typical psychological sex differences which proposes that females, on average, have a stronger drive to empathize (to identify another person’s emotions and thoughts and to respond to these with an appropriate emotion) whereas males have a stronger drive to systemize (to analyze or construct rule-based systems, whether mechanical, abstract, natural, or other) (Auyeung et al.,2009). Consistent with this theory, autistic individuals have more lateralization of the brain, like typical males, and some studies suggest a link between fetal testosterone level and autistic traits (Auyeung et al., 2009). Furthermore, a study found that females with GID had elevated autism spectrum quotient scores (Jones et al., 2012). Altogether, these studies provide a theoretical basis for a link between GID and ASD.”

People with gender dysphoria should be screened for autism:

“To conclude, we believe that it is important to consider the diagnosis of ASD in children, adolescents, and adults referred for a GID to evaluate the specificity of the demand of sex reassignment surgery or to guarantee the best condition of the success of the sex reassignment surgery.”

*There is a problem with this theory. It would only explain females who have both gender dysphoria and autism. In fact, there are many males with gender dysphoria who also have autism spectrum disorder – why would people with an “extreme male brain” feel that they were female?

The author of this paper worked with two male patients who had Asperger’s and gender dysphoria. The patients asked for hormones and surgery, but when treatment was withheld, they realized that they were not transgender.

The author concludes that:

“Patients asking for sex reassignment should be assessed for indications of Asperger’s syndrome. Irreversible treatments should be withheld until it is clear there is a genuine issue of transsexualism.”

The author points out that the incidence of Asperger’s Syndrome is above average in people with gender dysphoria. However, one of the characteristics of Asperger’s is obsessive preoccuptions (this can also be a good thing as the foundation for a hobby or career).

In the first case the author treated, the young man was socially isolated as a child, but had no sense of a female identity. At 21, he read a magazine article and decided he must be transsexual. He continued to believe this during four years of psychotherapy.

This doctor then treated the patient for six years. During this time, the patient rarely appeared dressed as a woman. He wanted hormones, but would not live as woman – apparently in Australia you must live three months as the target sex before you can get hormones.

The patient then went to live in a hostel for transsexuals where he discovered that he was not like them; he was not interested in clothes, make-up, or shoes. He realized that he was not transsexual and began to see a therapist who specializes in Asperger’s syndrome.

The doctor describes the second case this way,

“..when he was in Year 11 had worn his hair long and taken the name Marjory. He asked for hormonal transition but two psychiatrists and an endocrinologist wisely withheld hormones. He claimed that from the age of two years he had felt he was a girl. He would get emotional over trivial things – which he said was a female trait! At nine he was cross dressing, which continued into his teens.

He had always felt ‘different’ and over many years had a preoccupation with the ‘Star Wars’ saga and making model spaceships. At the age of 19 years he consulted me because of confusion over gender and sexuality – presenting, nonetheless, as quite a well-adjusted young man. Two years later he was able to say that ‘all that transgender business’ had been a waste of time and had put him a couple of years behind his mates in sexual development. Not long ago, three years after ending treatment, he told me he was married, expecting a child.”

The author is not opposed to allowing people with Asperger’s syndrome to transition; he talks about one case he had where a woman with Asperger’s presented in a very masculine manner and he helped her to transition to a man.

I am not sure what to think of this. The doctor seems sexist and the gatekeeping seems extreme – on the other hand, he was right.

The first case sounds like a good example of someone who wanted to believe he was transsexual in order to solve his problems, but did not really want to live as a woman. In the second case, the patient seemed more interested in actually transitioning, although when treatment was withheld, he decided that he was not transsexual.

The author also briefly discusses Baron-Cohen’s theories about autism:

“Given that there is an above average occurrence of ASD in young people presenting with gender dyshoria (the great majority male-to-female), it seems paradoxical that autism has been considered a case of “the extreme male brain.” Professor Simon Baron-Cohen has demonstrated that the number of autistic traits displayed in childhood relates back positively to levels of fetal testosterone. Baron-Cohen does not believe that gender identity is related to testosterone. However I am not alone in believing that it can be a factor, demonstrated for instance in the incidence of gender dysphoria in Klinefelter’s syndrome.

Hans Asperger himself wrote, ‘The autistic personality is an extreme variant of male intelligence … in the autistic individual the male pattern is exaggerated to the extreme.’”

IMPORTANT NOTE: There are a number of other case studies of patients who have both gender dysphoria and autism. Unfortunately, there are not any large studies of patients with gender dysphoria and autism spectrum disorders.

I highly recommend Gender and Autism on Musings of an Aspie. It includes an excellent discussion of the “extreme male brain” theory of autism.

You can read more about treating patients with autism and gender dysphoria in these articles:

This is a fascinating study of a group of children with gender dysphoria. The authors interviewed them as teenagers when some of them had lost their gender dysphoria and some of them had not.

Most children diagnosed with gender dysphoria do not go on to transition; their gender dysphoria goes away. Gender dysphoria faded at puberty for 84% of the children in previous follow-up studies.*

In this study, the authors identified 53 Dutch speaking teenagers that their clinic had diagnosed with gender identity disorder before age 12.** Among these 53 teenagers, 55% had reapplied to the clinic for transition while 45% had not. The authors do not address the question of why their patients were more likely to still have gender dysphoria than in past studies.***

The authors interviewed only 25 of the 53 teenagers; 14 teenagers who applied for sex reassignment (7 male and 7 female) and 11 who did not (6 male and 5 female). They say that:

All adolescents were approached, orally or in writing, to participate in the study. Based on the principle of saturation in information (Glaser & Strauss, 1967), 25 adolescents were interviewed.

This limits the conclusions that can be drawn from the data, however, this is a qualitative study. It uses interviews to explore the development of gender dysphoria in these teenagers. This allows the authors to find directions for future research.****

Based on their interviews with the teenagers the authors found:

1. There were no differences in childhood behavior between the group that lost their gender dysphoria and the group that did not.

2. Both groups identified as the other gender as children, but when they were interviewed as teenagers, they explained it differently.

3. Both groups were uncomfortable with their bodies as children, but they explained it differently as teenagers.

4. The teenagers who requested transition were all attracted to people of their natal sex while the teenagers who no longer had gender dysphoria were mostly attracted to the opposite sex.

5. The years 10-13 were critical in the children’s development; this was when they either lost their gender dysphoria or became more dysphoric.

6. Important factors related to the development of adolescent feelings about gender were: changes in the social environment, the physical development of their bodies at puberty, and falling in love and discovering their sexual orientation.

7. For some of the girls whose gender dysphoria had faded, it was hard to transition back because they had worn boys’ clothing and been perceived as boys.

8. One of the teenagers they interviewed felt half female, half male. He did not want to transition.

The authors of the study conclude:

“Based on the significance most adolescents attribute to the period between 10 and 13, we suggest that clinicians should concentrate clearly on what happens in this phase of development.

It is recommended to specifically address the adolescents’ feelings regarding the factors that came up as relevant in our interviews (i.e. the effects of the changing social environment, the response to anticipated or actual puberty, and the emerging romantic/sexual feelings and sexual partner choice), before any medical steps are taken (e.g. to suppress further pubertal development).

As for the clinical management of children before the age of 10, we suggest a cautious attitude towards the moment of transitioning. Given our finding that some girls, who were almost (but not even entirely) living as boys in their childhood years, experienced great trouble when they wanted to return to the female gender role, we believe that parents and caregivers should fully realize the unpredicatability of their child’s pychosexual outcome.

They may help their child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse. This attitude may guide them through uncertain years without the risk of creating the difficulties that would occur if a transitioned child wants to return to his/her original gender role.”

(Paragraphs and bold added by George Davis.)

Short version: Children should probably not transition socially before age 10. Parents and teachers should understand that the children may lose their gender dysphoria.

Therapists should work carefully with children who have gender dysphoria in the years between 10 and 13. Before giving them puberty blockers therapists should address the teenagers’ feelings about changing social relationships, puberty, and sexual development.

*The studies the authors cite followed a total of 246 children; only 39 of them had gender dysphoria after puberty, thus the overall persistence rate for the dysphoria was 16%. The persistence rate varied among the different studies from 2% to 27% (i.e. 73%-98% of the children stopped having gender dysphoria).

**The teenagers in the study were chosen from a total of 198 children who applied to their clinic between 2000-2007. The rest of the children did not meet the criteria for the study, although the authors don’t say if this was due to not being a teenager at the time of the study, not being diagnosed with GID, or not speaking Dutch.

***A few possibilities would be: a difference in the therapy given to the children (some therapies might be more effective than others), cultural differences in the countries where the studies were done (some cultures might make it harder to be gender non-conforming while others might make it easier to transition), a difference in the diagnostic methods (perhaps this clinic did a better job of diagnosing gender dysphoria), cultural differences in different eras, environmental differences in different eras (perhaps hormones are affecting children more now), or something about the way this study chose the 53 teenagers (this seems unlikely).

****A more serious question is that the authors do not say if they heard back from all of the teenagers they contacted. They cannot be sure that all of the teenagers who did not request further treatment were no longer dysphoric if they did not speak to them. This does not effect the results of their interviews, but it is an important issue.

This is a study of a trans woman who went blind, probably because she gave herself an overdose of estrogen which caused her to have a stroke. In addition to losing her sight, she is no longer able to take any estrogen.

The main conclusion from this study is follow your doctor’s advice when it comes to taking hormones.

The article goes into a detailed discussion of the individual case and their diagnosis and treatment of the trans woman. The patient was in her early 50s and had been diagnosed with gender dysphoria. Her doctor had already started her on androgen blockers.

These factors suggested that hormone therapy would be risky for her. The doctors put her on a low dose of transdermal estrogens and encouraged her to adopt a more healthy lifestyle.

The patient was doing well at losing weight and quitting smoking. Her hypertension persisted and she was given lisinopril 20 mg OD for it.

However, she was not doing well emotionally and was admitted to the Department of Psychiatry for several months for depression and “personality problems.” (I’m not sure what that last bit means.) The patient had been diagnosed previously with “mixed personality disorder with mainly cluster B traits” in addition to her gender dysphoria.

After 10 months of hormone therapy, the patient lost sight in one eye; six months later she lost some of her vision in the other eye. At this time they discovered that her estrogen levels were very high. The patient admitted that she had overdosed herself because she was impatient for feminization.

The authors conclude:

Both oral contraceptives in premenopausal and hormone replacement therapy in postmenopausal women are known to increase the risk for cardiovascular diseases, including cerebrovascular diseases (Sare, Gray, & Bath, 2008). Other cardiovascular risk factors, such as smoking, hypercholesterolemia, hypertension, and type 2 diabetes, play an even more important role (Lindenstrøm, Boysen, & Nyboe, 1993). It is advised that cardiovascular risk factors should be monitored and treated in transsexual persons before initiation of cross-sex hormone treatment (Hembree et al.,2009); however, no recommendations are available on a dosage reduction in sex hormone treatment in patients with cardiovascular risk factors.

In conclusion, we presented a case of bilateral non-arteretic anterior ischemic optic neuropathy possible associated to excessive estrogen therapy in a transsexual woman with co-morbidities. It is highly likely that these high estradiol levels were related to the cerebrovascular thrombosis and also played a role in development of the bilateral sequential NA-ION.

The authors suggest that cardiovascular risk factors should be monitored and treated before starting cross-sex hormone therapy. This is, of course, good advice.

However, the problem here was that the patient went against her doctor’s orders and overdosed on hormones. I would add a few conclusions to theirs:

1. Patients should follow their doctors orders when it comes to hormone doses.

2. Doctors should be aware that some patients may be extremely distressed and behave irrationally. They should clearly explain how long feminization takes and just as importantly, provide supportive therapy throughout the process.

3. Doctors and patients must work together as a team. Both doctors and patients have a role to play in creating that team. Patients must cooperate and be honest; doctors must earn the trust of patients.

4. We need more research on the safety of hormones and dosages for people who are older and/or in bad health.

5. We need more research on how to help someone with gender dysphoria who is unable to take hormones or who must take them at a low dosage.